Using photovoice to understand and improve healthy lifestyles of people diagnosed with serious mental illness

Accessible Summary What is known on the subject? People diagnosed with serious mental illness (SMI): Live 10 to 20 years less than the general population, and this can be related to lifestyle factors such as poor diet and low levels of physical activity. Have a good understanding of what healthy lifestyle comprises of, but face barriers and challenges related to their mental health, treatment, and life situation. There is limited participatory research that considers the specific beliefs of people diagnosed with SMI about what “being healthy” means to them. What this paper adds to existing knowledge People diagnosed with SMI value health and are often already engaged in activities that promote both physical and mental health. They experience the “vicious cycle” of barriers to engage in healthier lifestyle, including medication effects, poor sleep routines, fatigue, low mood and establishing a routine, but this shows how healthy activities can improve their mental health. The importance of meaningful places and their role in supporting healthy lifestyles was identified Some people diagnosed with SMI face significant socio‐economic challenges (such as lack of cooking facilities; limited money for purchasing healthy food) to support healthy lifestyles. To truly understand the perspectives of people with SMI, who are typically voiceless and disempowered, research methods need to allow the participants to set the agenda for discussion, to not only provide rich data but also have the added benefit of empowerment and enhanced engagement. What are the implications for practice? Mental health nurses should: Explore the practical barriers to healthy lifestyle such as financial concerns and ensure that people can access support to obtain what they need from the local community resources. Instigate a mental health and/or medication review if mental health symptoms or medication side effects are a barrier to healthy lifestyles Explore what places have meaning and consider how to use meaningful places as motivating factors for healthy lifestyles and promoting mental well being. Abstract Introduction People diagnosed with serious mental illness (SMI) live 10–20 years less than the general population, due in part to co‐existing physical illness linked to lifestyle factors. To inform individualized care plans to promote healthy lifestyles, it is important to understand the views of people diagnosed with SMI. To truly understand their lived experience, research methods should allow participants to set the agenda for discussion, enhancing engagement and empowerment in the research process. Aim To use a participatory research approach to capture what healthy lifestyle means to people who are diagnosed with SMI. Method Eight people diagnosed with SMI participated in six, weekly focus groups using Photovoice. Data were analysed using thematic analysis. Results The overarching theme was ‘mental health is the main priority’, and the other themes were barriers to a healthy lifestyle, represented as a vicious cycle, and three themes, which were facilitators ‐ the importance of place, meaningful activities, and the importance of others. Discussion The methodology allowed participants to choose images that reflected their lived experience. The themes describe the interaction of physical and mental health and practical barriers and will inform the design of individualized care plans. Implications for Practice In co‐designing care plans, mental health nurses should draw on peoples' preferences and explore the barriers identified in this study.

• Have a good understanding of what healthy lifestyle comprises of, but face barriers and challenges related to their mental health, treatment, and life situation.
There is limited participatory research that considers the specific beliefs of people diagnosed with SMI about what "being healthy" means to them.

What this paper adds to existing knowledge
• People diagnosed with SMI value health and are often already engaged in activities that promote both physical and mental health.
• They experience the "vicious cycle" of barriers to engage in healthier lifestyle, including medication effects, poor sleep routines, fatigue, low mood and establishing a routine, but this shows how healthy activities can improve their mental health.
• The importance of meaningful places and their role in supporting healthy lifestyles was identified • Some people diagnosed with SMI face significant socio-economic challenges (such as lack of cooking facilities; limited money for purchasing healthy food) to support healthy lifestyles.
• To truly understand the perspectives of people with SMI, who are typically voiceless and disempowered, research methods need to allow the participants to set the agenda for discussion, to not only provide rich data but also have the added benefit of empowerment and enhanced engagement.

What are the implications for practice?
Mental health nurses should: • Explore the practical barriers to healthy lifestyle such as financial concerns and ensure that people can access support to obtain what they need from the local community resources.

| INTRODUC TI ON
The life expectancy of people diagnosed with serious mental illness (SMI) is approximately 10 to 20 years less than the general population (Chesney et al., 2014;Laursen, 2011). SMI includes mental disorders such as schizophrenia-spectrum disorders, bipolar disorders, and severe major depression where there is significant functional impairment and limitation of major life activities (Ruggeri et al., 2000).
This increased mortality is due to high levels of co-existing physical illness such as respiratory problems, cardiovascular disease, and obesity (De Hert et al., 2011) and lifestyle and psychiatric treatment factors account for much of the increased risk of having these illnesses. For example, people diagnosed with SMI have higher levels of obesity (Coodin, 2001) and are often more sedentary compared with the general population (Daumit et al., 2005). Furthermore, antipsychotic drugs are significantly associated with weight gain (Newcomer, 2005), metabolic syndrome (Vancampfort et al., 2015) and type 2 diabetes (Vancampfort et al., 2016).
This has led to interventions to improve the physical activity of people diagnosed with SMI, and a review (Richardson et al., 2005) noted that regular physical exercise improved mental health, especially secondary psychiatric symptoms of psychosis such as depression and low self-esteem and that interventions that target specific groups and/or are tailored to individuals are more effective. The importance of individually tailored, or personalized, interventions is widely acknowledged in healthcare (e.g., The NHS Long Term Plan, 2019). These interventions should be informed by a good understanding of predisposing and precipitating factors contributing to the problem being addressed, and perpetuating factors that maintain the problem or are barriers to behaviour change.
Individual case formulations incorporate these components and are widely used in psychological therapy and mental health services (e.g. Pearson, 2008;Tarrier & Calam, 2002). They are informed by psychological theory and more effective in planning interventions than diagnosis alone (Macneil et al., 2012). Case formulations tend to be informed by general formulations, which are then adapted to • Instigate a mental health and/or medication review if mental health symptoms or medication side effects are a barrier to healthy lifestyles • Explore what places have meaning and consider how to use meaningful places as motivating factors for healthy lifestyles and promoting mental well being.

A bs tr ac t
Introduction: People diagnosed with serious mental illness (SMI) live 10-20 years less than the general population, due in part to co-existing physical illness linked to lifestyle factors. To inform individualized care plans to promote healthy lifestyles, it is important to understand the views of people diagnosed with SMI. To truly understand their lived experience, research methods should allow participants to set the agenda for discussion, enhancing engagement and empowerment in the research process.
Aim: To use a participatory research approach to capture what healthy lifestyle means to people who are diagnosed with SMI.
Method: Eight people diagnosed with SMI participated in six, weekly focus groups using Photovoice. Data were analysed using thematic analysis.

Results:
The overarching theme was 'mental health is the main priority', and the other themes were barriers to a healthy lifestyle, represented as a vicious cycle, and three themes, which were facilitators -the importance of place, meaningful activities, and the importance of others.

Discussion:
The methodology allowed participants to choose images that reflected their lived experience. The themes describe the interaction of physical and mental health and practical barriers and will inform the design of individualized care plans.

Implications for Practice:
In co-designing care plans, mental health nurses should draw on peoples' preferences and explore the barriers identified in this study.

K E Y W O R D S
care planning, formulation, health research, mental health services, photovoice, qualitative account for the unique circumstances for the individual. A better understanding of the beliefs, interests, values, and goals of individuals, what motivates them and barriers to behaviour change will support this individualized approach. More tailored approaches would also be more likely to improve self-efficacy, the belief the individual has the capability to be able to do something successfully, which is one of the most important predictors of health behaviour change (Holloway & Watson, 2002).
There is limited research that considers the specific beliefs of people about what "being healthy" means to them. Blanner Kristiansen et al. (2015) undertook interviews with people diagnosed with SMI with the aim of understanding what they thought are the causes of physical health issues, what types of issues they experienced, and what could be done to prevent these issues. The participants regarded physical and mental health as inseparable and identified a significant impact of living with an SMI on their physical health, energy, and motivation, and the impact of medicines and dealing with symptoms of SMI. Blomqvist et al. (2018) undertook 16 qualitative interviews with people with SMI in Sweden asking "how healthy living has influenced own health, the experiences of trying to change unhealthy habits, and what helps support healthy living". They identified a main theme of being regarded as a "whole human being" in that physical health is an important aspect of holistic care. Other themes identified included being able to get outdoors, importance of structure and planning and support from significant others. These studies offer useful insights but were based on discussions led by researchers and therefore limited to the parameters of the study. To truly understand the perspectives of people with SMI, who are typically voiceless and disempowered, participatory research methods that allow the participants to set the agenda for discussion not only provide rich data but also have the added benefit of empowerment and enhanced engagement.
A community-based participatory research (CBPR) approach was taken using Photovoice, a method where photographs are used as an elicitation tool for facilitating discussion and sharing experiences. Caroline Wang and Mary Ann Burris developed Photovoice, a visual research methodology, which enables people to record and reflect on issues facing their community and their day to day lives (Wang & Burris, 1997). Photovoice encourages critical dialogue and knowledge about issues of concern through group discussion, with the intention to create change. Underpinning this approach is the idea that the visual image enables people to identify and think critically about problems/issues central to their lives more easily. Using a camera is also accessible and inclusive of those who do not read, write, or speak the dominant language, and those living with stigmatized health conditions, such as SMI. Photovoice is an approach, which recognizes that it is the people living in those communities who have the expertise and insight, not the professionals. Adopting such an approach has the potential to be empowering, accessible, and inclusive of those who are often passive subjects to health policy and practice (Wang & Burris, 1997). Photovoice has been used in research with people diagnosed with SMI, including Cabassa, Nicasio, and Whitley (2013) who found photovoice helped people diagnosed with SMI living in supportive housing in the US to communicate life experiences related to their health, and to formulate solutions. Their work led to the development and testing of a peerled healthy lifestyle program focused on weight loss, cardiorespiratory fitness (CRF), and cardiovascular disease (CVD) risk reduction (Cabassa et al., 2015). Findings indicated that peer-led group lifestyle balance (PGLB) was not superior to usual care in helping participants achieve clinically significant changes in weight, CRF, and CVD risk reduction (Cabassa et al., 2021), which emphasizes the difficulties achieving positive outcomes for people diagnosed with SMI and the importance of identifying barriers to change. By engaging them in an exploration of the barriers and facilitators, and what a healthy life is to them, we hope the findings of this study will help us to understand factors that should be taken account of when designing personalized approaches.

| AIM
The aim of the study was to work in partnership with people diagnosed with SMI to understand what healthy means to them, and the barriers and facilitators to living a healthy lifestyle. Understanding this will help the development of personalized formulations and interventions to improving healthy lifestyles of people diagnosed with SMI.

| Design
A 'community-based participatory research' (CBPR) approach, using a focus group over 6 weeks and Photovoice, to ensure a participantled and lived experience perspective.

| Sampling and recruitment of participants
The study aimed to recruit a sample of eight participants as this is the optimum number for a focus group (Stewart & Shamdasani, 2014) and consistent with previous photovoice studies (Cabassa, Parcesepe, et al., 2013). Purposive sampling was used to recruit people in receipt of care from a community mental health team (CMHT) with serious mental health conditions and equal numbers of males and females. Twelve "consent to contacts" were received of which nine subsequently consented to participate. The remaining three were ineligible for the study; two did not have a diagnosis of SMI, and the other was in hospital at the time of completing the consent to contact form. One person who consented to participate in the research subsequently withdrew because they moved out of the area. Eight adults, five males, and three females, aged between 31 and 53 years participated in the study.

| Setting
A publicly funded NHS community mental health service in a provincial city in the North of England, UK. Life expectancy for men and women living in this city is lower than the England average (Public Health England, 2019). The wider local authority area from which participants were recruited has an Index of Multiple Deprivation (IMD) of 54 out of 317 local authorities in England (where 1 is the most deprived).

| Recruitment
The CMHT case managers approached potentially eligible participants on their caseloads, gave leaflets about the study, and obtained "consent to contact" if the service user expressed an interest in the study. Researcher (RB) then met with potential participants to talk through the study process, and the Participant Information Sheet.
Potential participants were given at least 3 days to consider their participation, before giving written informed consent.

| Ethical and governance approval
The study was given a favourable opinion by a UK National Health

Service (NHS) Ethics Committee and approved by the UK Health
Research Authority. The consent form and patient information sheet made it clear that if anyone disclosed risk of harm to self or others, the researchers would have to contact emergency or mental health services as appropriate. All data were stored in compliance with the General Data Protection Act, (2018) and electronic data stored on the NHS Trust secure network drive with password protection. Data were anonymised using pseudonyms, and potentially identifiable audio-recorded information was anonymised where necessary during transcription. Photos in which other people could be identified were not included, and this was made clear to participants.

| Photovoice method
This method was crucial to the study in that it ensured a participantled enquiry based on lived experience. Photovoice uses photographs taken by participants as visual prompts to facilitate discussion to communicate aspects of their lived experiences through visual images and accompanying narratives (Minkler & Wallerstein, 2008).
Rather than fitting experiences to predetermined questions, the active process of using participants' photographs encourages them to consider what is important to them (Harper, 2002;Wells et al., 2012), which is more likely to lead to an understanding of the realities of a person's life and feasible and effective interventions.
The photovoice procedure and the photo-sheet were adapted from guidance provided by Amos et al. (2012).
Six weekly group sessions were conducted, each lasting approximately 2 h. The first session familiarized participants with the aims (to generate knowledge about what health means to people diagnosed with serious mental illness) and structure of the sessions, instruction on how to use the cameras and confidentiality issues.
Participants were asked to spend time throughout the following week taking (unlimited) digital photographs that in their view related to a topic chosen by the group.
Each of the subsequent sessions followed the same format. First, a one-to one discussion with a group facilitator (AE, RB, ML, EH) to review the photos and selection of one photograph by the participant that they felt best illustrated the theme of the week. This was printed and the participant gave it a caption/title.

| Analysis
The photographs, notes taken at the 1:1 sessions and transcriptions of the focus groups were analysed using thematic analysis as described by Clarke (2006, 2019) and polytextual thematic analysis as described by Gleeson (2011Gleeson ( , 2020. Polytextual thematic analysis acknowledges and enables more than one type of data to be analysed. It essentially follows the same key stages as a thematic analysis but moves between textual excerpts and images in the early stages of familiarization with the data and creation of basic explanatory codes. For example, each (group) transcript and set of images was scrutinized for themes in an iterative process that involved moving back and forward from text to images. Initially, textual excerpts and images were scrutinized and extracts of text that were deemed noteworthy were highlighted and qualities within the pictures were noted. The next stage was the creation of explanatory codes (a basic unit of meaning) that could be applied to the textual excerpts and images that conveyed the interpreted meaning. Following this stage, the data were managed as one source (a list of codes with their associated images and text). All coded textual data and images were then reviewed for fittingness by reviewing the text and visual data associated with each code to ensure all the data shared the same meaning. If different extracts of data or images differed in meaning, then codes were expanded (or collapsed if different codes had a shared meaning). Codes with similar properties were grouped into tentative themes, which were then refined and their boundaries demarcated by further scrutiny of the images and text that had informed the themes. Finally, each theme was defined and named.
The analysis performed by researchers (RB, AE) was data driven and inductive and discussions on the different stages of analysis involved AE, RB, and ML.

| RE SULTS
A total of eight people were recruited to participate in the study.
On average, five participants attended each week. One participant attended session one only due to difficulties travelling to the group.
Travel costs were provided; however, issues with mental health were a barrier. Despite this, the researchers (AE and/or RB) continued to make weekly telephone contact, and the participant continued to take photographs and provide written notes each week (using the photosheet provided). Twenty nine photographs were collected out of a possible 32 (eight photographs per sessions two to five). Participants did not talk about physical and mental health as two separate concepts. Their main preoccupation and motivation was to be mentally well but they also recognized that many things that improve physical health (good diet, fresh air and exercise, reducing smoking and caffeine) also improved their mental health. When describing what healthy meant to them, participants described it as "feeling complete"; "feeling full"; "normal"; "being busy"; "finishing my goals".
It therefore included subjective wellbeing such as feeling "normal" and a behavioural element-achieving goals and being occupied, which helped them feel healthy (more "capable", "complete" and "busy").
it's about being stable really about being you know kind of complete innit you know…it's kind of full really you know like you've got this going on here that going on there … there's loads of words I could think of like progress and being stable and being happy and things like that but to be complete to me it's about finishing my goals really (participant 7, male) Here is an example of a personally meaningful activity for one participant:

| Theme 2: "it's like a vicious cycle"
Participants identified factors associated with living with a serious mental illness, which served as significant barriers to making healthier lifestyle choices. It was clear that these factors could at times compound each other and become a vicious cycle. An example of this, shown in Figure 2, is the experience of side effects of psychotropic medication such as weight gain, disturbed sleep, and fatigue. This, together with self-medication such as caffeine and smoking, leads to difficulties planning, establishing a routine and self-care, leading to difficulties engaging in meaningful activities and low mood. Social isolation and limited finances also contribute to the negative cycle.
There was a lot of discussion around medication for mental health and comorbid health issues. Participants readily acknowledged the need for psychotropic medication but also described how

| Theme 3: importance of place
The importance of "place" came up repeatedly in the discussions. Another participant chose to photograph a caravan and fishery site.
He described how visiting the caravan site gave him "a good health feeling". He described eating healthier, exercising more (walking the dog), and sleeping better because of the fresh air when at the site.

| Theme 4: meaningful activities
Participants discussed various activities, which gave them a sense of achievement and enjoyment and served to facilitate feeling healthy.
For example, cooking (cooking for others, being cooked for), walking with others, or alone at night. One female participant described how walking at night was more pleasurable as it felt more leisurely and less pressured (she had nowhere to be), for her the pleasure outweighed the risks. Other activities included fishing, listening to music, drawing, exercise, and attending the weekly photovoice group.

I like to sit in his chair to relax -it calms me down when I'm anxious." (participant 5, female)"
One participant took a photograph of his own artwork alongside a speaker and described how the photograph not only captured his hobbies but also how he gauged his mental health in relation to his hobbies: During the week when the theme was 'food', two of the participants brought along photographs, which captured food; however, the accompanying narratives revealed more about how the associated activity, i.e., food shopping and cooking a meal, enabled a sense of achievement and purpose: Activities involving the gym were described as difficult due to fatigue and lack of confidence by most of the participants, and one participant described how he chose to exercise at home. Where physical exercise was clearly the focus of the photograph (see below), the narrative also described how exercise helped their mental health through giving them "something to do" helping them "feel more confident and happier" and feeling more energized:

| Theme 5: importance of others
For some participants, people (support staff, peers, family) and family pets were a key factor in facilitating a healthy lifestyle in different ways. For some, it was about having someone to do things with, such as walking the dog, going to the gym. For some, it was having someone to do things for, such as people to cook for, pets to care for. For others, it was having someone who supported and cared for them, someone to support their own 'self-care' (e.g., cooking you a healthy meal

| DISCUSS ION
There is limited research on what healthy lifestyles mean to people with SMI. Previous studies have identified that an individualized approach to health is important and that people with SMI face specific challenges that need to be overcome to adopt healthy habits. The aim of this study was to take a participatory approach to allow participants with SMI to lead and drive the discussions in relation to understanding what "healthy" means to them. A key finding, reflected in the overarching theme 1, was that the participants mainly saw "healthy" as relating to their mental well-being, but they also informed us that many activities that focused on physical health also improved their mental well-being (e.g., going for a walk in nature). Therefore, when promoting activities that aim to promote physical health, such as using the gym, walking, cooking groups, it may be more engaging to also acknowledge and promote the mental health benefits of these activities. In addition, people told us they are highly motivated by their own past and current interests so healthy living interventions should be flexible enough to harness individual interests, passions and capabilities, and provide support when necessary. One novel theme that emerged was the concept of feeling locked in a vicious cycle related to the interactions of the illness, medication, and lifestyle factors and how this can negatively impact on motivation, mood and self-care. The relationship between low activity levels and low mood is well known (Elfrey & Ziegelstein, 2009), but this study highlighted additional factors that are prominent for people diagnosed with SMI, such as the effects of medication, poor sleep routines, and fatigue. The correlation between sleep problems and mental health has been established (Baglioni et al., 2011;Benca et al., 1992) and this study suggests that for people diagnosed with SMI the sedative effects of psychotropic medication and self-medication (caffeine and smoking) may partly explain this relationship.
The participants also told us about some of the practical barriers they face in their daily life due to the socio-economic impact of living with a long-term mental illness. Limited finance, and skills and resources, experienced by participants, and for those diagnosed with SMI in general (Macintyre et al., 2018), such as lack of money, inadequate cooking facilities, and limited skills to cook fresh meals acted as significant barriers. These barriers reflect social inequalities (Marmot, 2010), which contribute to the poor health of people diagnosed with SMI. These factors were all barriers to planning and carrying out activities that could improve wellbeing. The relationships between these factors is represented in Figure 1, and this is an example of a general, nomothetic, formulation that can be used and adapted for individuals and to design personalized interventions.
It is important to consider how to overcome the barriers identified in this study and behaviour change approaches such as behavioural activation (Ekers et al., 2014) and implementation intentions (Gollwitzer & Sheeran, 2006) (2012); Russinova et al., (2018)).
Personalized plans that tap into past and present interests and passions and that give people a sense of meaning, purpose, and achievement will be more effective, and this is recognized through social prescribing approaches (Friedli & Watson, 2004;NHS England, 2014), which often includes social and peer support. There are good examples of such approaches for people diagnosed with SMI (Fancourt & Finn, 2019), and our study also highlighted the importance of 'place' as well as personally meaningful activities. These were situations where the participants felt more at ease, for example, green space and walking at night-time. (Fancourt & Finn, 2019;Friedli & Watson, 2004;NHS England, 2014). Our study suggests there should be more focus on places and the settings in which activities take place, as well as types of activities. (Cabassa & Stefancic, 2019).

| Strengths of the study
A participatory research method (Photovoice) was used to empower participants to drive the agenda regarding the specific topics to discuss. The participants worked with the researchers over six sessions not just a single time point, which allowed for relationships and trust to develop (both between the group members and the group facilitators) and for rich understandings of current lived experiences and meaningful issues to emerge.

| Implications for practice
Attention to physical health and healthy lifestyles as a part of mental health care is well established, but it is vital that mental health nurses recognize the additional challenges that people diagnosed with SMI face. Individually tailored interventions to promote physical health should consider the multitude of challenges that they face in trying to make healthier choices. These can include treatment factors such as medication effects and side-effects, lack of money to access sport or buy healthy food, and low mood and lack of motivation. Mental Health Nurses are expected to undertake assessments of physical health needs (Haddad et al., 2016), but this needs to be more than a checklist and should be a holistic assessment performed in partnership with the person to understand their own motivators but also identify their specific challenges. Mental health nurses are in a key position to adopt an empowering approach where people with SMI should lead the conversation about healthy lifestyles and what would work for them given their own unique set of circumstances. Activities advertised as promoting health (such as walking groups) should also acknowledge the mental well-being benefits as well. Mental health nurses should enquire about potential challenges to healthy living and be able to assist or mitigate these issues (such as adverse effects of medication, poor sleep routines, fatigue and difficulties with motivation, low mood, and establishing a routine). Incorporating healthy activities in their daily lives of people diagnosed with SMI should take account of their interests and passions, the priority they place on their mental health, the importance of the "place" in which healthy activities take place and the need for direct support.

| RELE VAN CE S TATEMENT
There is a significant health inequality for people diagnosed with SMI. This study used a participatory method (Photovoice) to capture lived experience and sheds light on the challenges they face on a day-to-day basis in the adoption of healthy lifestyles.
The findings will help inform mental health nurses how to address health promotion through individualized conversations that identify specific barriers, being able to advocate or address some of the barriers and work with peoples' interests, choices, and preferences in devising achievable and meaningful goals. It is vital that mental health nurses recognize the challenges that people diagnosed with SMI face.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

E TH I C A L A PPROVA L
The study was given a favourable opinion by a UK National Health Service (NHS) Ethics Committee (reference 17/NW/0282) and approved by the UK Health Research Authority. Patient consent to publish the findings, including images, in journal articles has been obtained. The study conforms to recognized standards, e.g.,